10
The Bulletin
• Evaluation of infants with risk factors for DDH: Moderate
evidence supports performing an imaging study before 6
months of age in infants with one or more of the following
risk factors: breech presentation, family history, or history
of clinical instability.
• Imaging of the unstable hip: Limited evidence supports that
the practitioner might obtain an ultrasound in infants less
than 6 weeks of age with a positive instability examination
to guide the decision to initiate brace treatment.
• Imaging of the infant hip: Limited evidence supports the
use of an AP pelvis radiograph instead of an ultrasound to
assess DDH in infants beginning at 4 months of age.
• Surveillance after normal infant hip exam: Limited evidence
supports that a practitioner re-examine infants previously
screened as having a normal hip examination on
subsequent visits prior to 6 months of age.
• Stable hip with ultrasound imaging abnormalities: Limited
evidence supports observation without a brace for infants
with a clinically stable hip with morphologic ultrasound
imaging abnormalities.
• Treatment of clinical instability: Limited evidence supports
either immediate or delayed (2–9 weeks) brace treatment
for hips with a positive instability exam.
• Type of brace for the unstable hip: Limited evidence
supports use of the von Rosen splint over Pavlik, Craig, or
Frejka splints for initial treatment of an unstable hip.
• Monitoring of patients during brace treatment: Limited
evidence supports that the practitioner perform serial
physical examinations and periodic imaging assessments
(ultrasound or radiograph based on age) during
management for unstable infant hips.
Late-presenting DDH
It is difficult to ascertain the “normal” rate of missed DDH diag-
noses in neonates, but a large randomized controlled trial in Norway
looking at ultrasonographic screening found that the prevalence of
late subluxation/dislocation was 0.3 in 1,000 for universal ultra-
sound screening, 0.7 in 1,000 for selective ultrasound screening,
and 1.3 in 1,000 for no ultrasound screening.
At Seattle Children’s Hospital, we found that breech infants and
patients with known positive family history of DDH were significantly
less likely to present late with DDH even after factoring other vari-
ables. These findings can be interpreted as a sign that our current
screening algorithms are working for these known high-risk popu-
lations since these children are over-represented in the early diag-
nosis and treatment groups. We also found that non-white race
and foreign language-speaking households, and estimated income
based on zip code were associated with late-presenting DDH groups.
Clearly these factors are closely interlinked with each other
Examination of infant
There are no pathognomonic signs of a dislocated hip, and a stable
dysplastic hip has no physical findings. The physical examination
requires patience on the part of the examiner with a quiet and calm
infant. This may be facilitated by having the baby feed from a bottle
and dimming the room light. An evaluation for asymmetry of hip move-
ment is an important key to the evaluation of DDH, with the presence
of limited and asymmetric flexed hip abduction being suggestive of
a dislocation, although asymmetry may not be evident in bilateral
dislocations. The presence of asymmetric thigh folds may be indica-
tive of DDH but is present in up to 20 percent of unaffected infants.
Asymmetric thigh folds in the absence of other physical examination
findings should be considered a nonspecific finding and does not
require further imaging or workup. High-pitched “clicks” are frequently
elicited with the hip motion. These sounds are most frequently attrib-
uted to snapping of the iliotibial band over the greater trochanter, a
normal occurrence, and are not associated with dysplasia
Limited hip abduction
Hip abduction is performed with the hip in flexion, and side-to-side
variations should be noted. An arc from 30 degrees of adduction
to 75 degrees of abduction should be easily obtained when the
infant is in the supine position. Limited hip abduction (a difference
of 20 degrees or greater between hips) is the most reliable exami-
nation finding suggestive for DDH in babies older than 12 weeks.
Galeazzi sign
The Galeazzi sign is elicited with the patient placed supine on an
examining table so that the pelvis is level, with the hips and knees
flexed to 90 degrees. With the baby’s hips in neutral abduction,
the examiner determines if the knees are at the same height. If
one femur appears shorter, the hip may be dislocated posteriorly.
Barlow sign
Originally described by Barlow in 1952, this test is an attempt to
dislocate or subluxate a reduced but unstable hip. The thigh is held
and the pelvis stabilized in the same manner as for the Galeazzi test.
With the hip in neutral external/internal rotation and at 90 degrees
of flexion, the leg is gently adducted with a mild posteriorly directed
pressure applied to the knee. A palpable sensation of a marked
posterior movement over the acetabular rim constitutes a positive
result, meaning the patient has a reduced hip at rest that can be
dislocated. Each hip should be examined separately.
Ortolani sign
The Ortolani test determines if the femoral head is sitting outside
of the acetabulum and can be reduced. Originally described in
1937, the Ortolani maneuver is performed one leg at a time, with
hip health, cont.
